Abstract:This article describes the centralization of the therapeutic
work on the aspects of everyday life of the users’ mental health service,
emphasizing psychosocial rehabilitation, while a social practice geared
towards the rebuilding of identities and possibilities for mentally ill
people. This study was developed at the Mental Health Community Center
in São Lourenço do Sul/RS, Brazil, the so-called "Nossa Casa",
taken as a practical mark in a new way to approach mental diseases. This
research consists of a qualitative study in which we make use of the Marxist
referential, with the dialectical materialism as a theoretical substrate
in order to interpret reality. The instruments used were semi-structured
interviews with ten persons from the mental health staff. The thematic
analyzed consisted of the centralization of therapy work on the average
users’ life aspects focused by the interviewees, such as the possibility
of searching autonomy and citizenship.

This study was developed at the Mental Health Community Center, São
Lourenço do Sul/RS, Brazil. The mentioned institution is characterized
by offering integral attention to mentally ill patients, through a network
of attention services to mental health. This institution started to be
structured in the year 1988 attending the initial necessity of taking care
of mentally ill patients in town. The Mental Health Community Center comprises
a mental health network, as follows: Psychology and Psychiatry Ambulatories;
"NOSSA CASA" – CAPS - Psychosocial Attending Center and the parent-cell
of the project; Therapeutic workshops; a Psychiatric Unit at the General
Hospital; Children and Adolescent House; "Nosso Lar"- protected home. The
network is accredited by "Sistema Único de Saúde" (SUS) and
gives attendance to the rural and urban population of the municipality.
The mental health service runs daily, from Monday to Friday, through interdisciplinary
teams. The emergencies are attended at the local hospital, which is the
entrance door for hospitalization cases. In "NOSSA CASA" the daily average
number of users is from 25 to 30 patients. The number of attendance is
about 1.300 patients per month.

The users of the Mental Health Community Center comprise patients with
mild to severe mental disorders – neurotics, psychotics, those discharged
from psychiatric hospitals, organic psychosis. The average time for internment
in the Psychiatric Unit is approximately 10 to 12 days, a considerably
short time, because as soon as the patient shows improvement on the reasons
that took him/her to the hospital, he/she is then transferred to "NOSSA
CASA". In this place the remaining time is discussed with the team, and
also factors and factswhich were relevant for the current situation,
such as his/her familiar situation, social network, employment, among others.

"NOSSA CASA" team is composed by one nurse, two nurse attendants, eight
therapeutic attendants, a psychiatric doctor, three psychologists, one
home economist, two general service attendants, one cook, one driver and
one office boy. One of the authors (A. H.) used to work in this duty for
10 years as a therapeutic attendant, as a nurse and as an administrative
coordinator.

The Mental Health Community Center is aimed towards the community mentally
ill patients under the perspective of psychiatric reform, and focuses on:
(i) permanence of patients in their own environments, them patients to
remain closer to their families and social environments; (ii) integral
attendance to meet individual needs; (iii) the respect of individual differences;
(iv) rehabilitation practices and social reinsertion.

The path of the study

This is a qualitative study that uses the Marxism referential, the dialectic
materialism, as a theoretical background for the interpretation of reality.
Abstracting the question negation-overcoming for the referential of psychosocial
rehabilitation from the dialectic conception, we considered necessary to
deny the assistance reality of the individuals with mental problems centered
in the model of the damage, in the deficit towards the rescue of centralization
of the focus in the abilities, and the search of work to reach the aims
of psychosocial rehabilitation, citizenship and quality of life.

We recurred to the definition of psychosocial rehabilitation produced
by experts from several countries and compiled in a document called "Declaration
of Consensus in Psychosocial Rehabilitation" which states that psychosocial
rehabilitation is a process which facilitates the opportunity for the individuals
– who are prejudiced or disabled by a mental disorder – to reach a great
level of working independence in the community. This implies both professionals
and users to improve competences and introduce environmental changes in
order to create a better quality of life possible to people who experiment
a mental disorder, or have a mental deterioration which produces a certain
degree of inaptitude (WHO/MNH/MND/96.2).

The instruments used were semi-structured interviews with ten integrants
of the mental health team. An official letter was sent to explain the thematic
of the research requiring collaboration in the phase of interviews. Thus,
the conventional directions started and the subject was discussed in meetings
of the team. After the testing of the instrument (the interview itinerary)
the ten semi-structured interviews were performed with the workers from
the Mental Health Community Center, such as, psychologists, psychiatrics,
therapeutic attendants, nursing attendants and workshop instructors. As
a delimitation criterion, the individuals were selected among the employees
working for, at least, five years in the institution. The interviewees
are identified in the text by letter "A" and the number of the interview
(for instance: A1, A2, …).

Centralization of therapeutic work in the aspects of users’
everyday

This thematic area contemplates the actions of the individuals, in their
the everyday service and the importance attributed to the different practices
of psychosocial rehabilitation. The user’s conception, while a person not
as a nosologyc adding leads the actions for intervention centered in the
individuality of each human being. The approach in everyday life aspects
constitutes itself in attendance practices implanted in the service. The
practices considered consistent with the philosophy of doing but not ruled
on the traditional model are addressed. Dissociation between illnesses
and person is evidenced, and also the centralization of practices toward
the person, without disregarding the aspects concerning the treatment.
The practices of everyday life are the first step
for psychosocial rehabilitation of the individual and, mostly what makes
one a citizen… When we give a person a treatment we treat things differently
than when we treat a diagnostic. This is the practice of this service.
To treat people, citizens. With identification card, address, family (A1).
Goldberg (1996a, 1996b) emphasizes that in front of the patient we cannot
place ourselves a priori in the knowledge of the object. He illustrates
that with the psychiatric clinics, in which he always tries to learn with
the patients’ disturbs, not to reproduce them. He also suggests that the
centralization towards the symptoms constitutes itself the referential
adopted in institutionalized models, which reduces and includes the patient
in standardized behavior, independently of the presented psychosocial characteristics.
The clinics, according to the author, based on institutionalized models,
admits typifying the manifestation of diseases, while a strategy to reach
the specificities. However, he emphasizes that only an operative and an
ethics clinic will be able to establish differentiated therapeutic interventions.

We understand that the new services should correspond to a renewed clinic,
with differentiated treatments, and where concomitantly or in sequence,
therapeutic projects that contemplate the psychosocial needs of the involved
people be developed. This is what might effectively bring a person to be
a citizen. It is important to point out that the projects cannot constitute
themselves as models built from professionals, but built collectively with
the most interested people: the users.

According to Saraceno (1999) the services are constituted as a variable
that has influence on the rehabilitative process. The author points out
the capacity of the service in looking after all patients and giving them
possibilities of rehabilitation as a high quality service. He states that
the services, which do not offer these possibilities, generate intervention
hierarchies and those who are less qualified are excluded from the process.
Saraceno (1999:96-97) points out that a high quality service should be
permeable and dynamic, with high internal and external integration "… a
service where the permeability of knowledge and resources prevail on the
separation of them", and in which the organization is "oriented towards
the necessities of the patient and not the service".

We understand that internal and external integration is due to the movements
which transpose the treatment and the psychosocial rehabilitation. This
integration will be possible and concrete if professionals visualize the
importance of no dissociation, and assume both the treatment and the rehabilitation.
The idea of this proposal faces a resistance that is sometimes established
in everyday services: the treatment given by some and the rehabilitation
by others.

In "Nossa Casa", most of technicians are detained on the treatment and
on the formulation of rehabilitative proposals on intellectual level, while
non-technicians make the proposals to work on a practical level, that is,
a separation between who provides treatment and who provides rehabilitation
prevails. The attempts of re-approximation occur through meetings of the
team, where specific cases are discussed individually, and where a rescue
and an integration of both treatment and rehabilitation are approached.

Bandeira (1994), analyzing the importance of communitarian infrastructure
in the social re-insertion program, in a controlled group evaluated during
three years, concluded two essential aspects for the increasing of successful
probability of mentally ill patients social reinsertion, such as, quality
of the program, where the basic abilities for everyday life in the community
is included, individualized follow-up and attendance to patients in crisis.
The second aspect is concerned to the quality of home environment. Patients’
active participation in the activities of the house, the establishment
of objectives, individualized orientation is included in this item.

We try to make our patients to retake their lives
closer to reality, as much as possible. We try to make them retake some
daily activities that they have lost, sometimes, because of the illnesses.
Activities like personal hygiene, …, shower, shaving, nails, hair, in order
they get their vanity back. Besides, we try to retake some activities with
them, some in the kitchen-garden, who have already done this kind of work,
others in carpentry, others in protected factories… To try to look after
their own houses, to take care of their own lives, to have leisure… (A9).
Through the talk it gets clear that the centralization of therapeutic work
firstly begins on the difficulties installed with the illness, in relation
to the development of activities people can do in their everyday life.
That is, common elements of a person’s everyday life are worked, which
for people who have disabilities or are handicap are not really common,
to gradually open the options of intervention. The rehabilitation process
has its beginning in everyday activities, such as to take care of their
own body. Then, the aspects concerning activities developed before the
illnesses are worked on. The work runs from a protected context to the
occupation of real spaces in the community. The users’ priori abilities
are considered and reinforced, and the disabilities are worked.

Bandeira (1998), searching psychotics’ social competence, through social
validation of specific abilities, regarding verbal, non-verbal, paralinguistic,
of expressivity’s components and abilities of solving problems, concluded
that the higher difficulties happen in relation to the verbal component
and problem solution. The aim of the author was to evaluate the training
of social competence of mentally ill patients, compared to a reference
group of their own community. According to Bandeira’s (1998) review of
literature, the results of social abilities training improved the level
of social competence and decreased the number of patients’ re-hospitalization.
The author understands that the efficacy is higher when many components
and several social situations are worked. She also highlights the importance
of including the practices performed in the natural setting where the patient
is inserted.

From this research we can apprehend the importance of recognizing the
environment in which the individual is inserted, so that the formulated
proposals be coherent with the social environment and its demands for mentally
ill people. We understand that the environment contextualization, the culture
in which the person is inserted works as a thermometer in determining the
validity and importance of the aspects to be focused in the training of
social competence.

When a person is treated, his/her inter-relations,
way of dealing with the family, with the work, with the house, with the
recreation, with that entire are treated. What is good for myself is good
for the employee and is good for the patient.The
traditional practices many times forget this. From the point of view of
clothing, name, housing, of all these concepts which are very important
for us and that become important in the model of psychosocial rehabilitation,
where we first rehabilitate the person, his/her working conditions, then
his/her condition out of the treatment. (A1)
The work also appears as a rehabilitation factor on the interviewees’ speeches.
It is important to highlight that this is not as accessible to mentally
ill patients as it seems to be. This is a reality which cannot be denied,
mostly if we consider that São Lourenço do Sul is a small
town, with relative difficulties in work market for the "normal individuals".
This reality is not different from the reality in other cities, with similar
population characteristics. Regarding big cities, difficulties will certainly
be bigger: firstly, the dispute for job is bigger, and, secondly, small
centers probably take advantage regarding protected work.

We have mentioned a situation that has been characterized as a protected
work: daily patients followed by an attendant used to go to a big workmanship,
which was going to be repaired to be a branch of a supermarket in the city.
These users, in a protected policy, worked effectively on civil construction.
Businessmen who welcomed the proposal followed the whole process. The work
for mentally ill patients, besides the challenge which represents, needs
primordially discussion on mentally ill patients’ rights and the recognition
of these rights by society.

According to Saraceno (1999, p. 131) "… the work is identified as an
"instrument" of rehabilitation, subordinated to healing and, successively,
as an indicator of success of the healing itself, thus, a return to normality
indicator".

Some authors like Cohen (1990), Ciardello and Bell (1991), Pitta (1996),
Saraceno (1999) and Pratt et al (1999) have deeply discussed about the
work while a promoter of psychosocial rehabilitation having in one’s mind
the possible benefits acquired in the personal, relational and communitarian
context, deriving from there. The occupational rehabilitation (vocational
rehabilitation), principally in the Anglo-Saxon model of psychosocial rehabilitation,
is explicit as a central principle of the process. In the pragmatic model,
people are requested to produce in economical terms. In Latin American
countries, a focus has been given on the rights of mentally ill patients.
This is a basic necessity to be worked with society. Without this previous
understanding from society, the effective occupational rehabilitation will
not have chances to be materialized as a right, but as a concession.

Rehabilitation, according to the interviewees, is divided into distinct
moments in which "… first we rehabilitate the person, his/her work condition,
then his/her life out of the treatment" (A1). Goldberg (1996b) points out
that treatment and rehabilitation are in dissociable. He states that for
a patient to be rehabilitated it is necessary to offer continuous treatment.

We understand that the initial treatment of productive symptoms is the
first intervention to be done. Within a broader perspective, we consider
the diagnosis of this person’s life extremely important, and the subsequent
establishment of a therapeutic project from the context in which the person
is inserted. They must be sufficiently flexible to incorporate changes,
and to possible re-dimension. We highlight the necessity of readingthe
context within a change of optics. Usually this reading is done over the
deficits, the negative aspects. To emphasize the forces, the health aspects,
is an important transition in the treatment and rehabilitation process
is as well as the notion in unsociability of both of them.

Liberman (1998) states that the programs of communitarian support serve
as environmental protectors, through the reduction of harmful effects of
the critics, absence of support, social and emotional over involvement
in vulnerable individuals. According to the author, communitarian support
might strengthen the protective effects in the training abilities of chronic
mentally ill patients. The author points out that the learning of abilities
to solve problems, conversation and vocational abilities, and self-help
abilities, within a communitarian support context, capacitate the vulnerable
individualsto establish realistic aims and to promote clinical
and social aspects. Communitarian participation is viewed as the responsible
for the decreasing of recurrence and for a suitable social adjustment.
As well as the learning for changes and to solve problems of everyday life.

I am going to quote some examples that we use in
our everyday life… we have here a big group which we take it to play soccer;
there are two schedules and gymnasiums and take these people. So, about
fifteen people we always take (A2).

We also have leisure activities. Soccer, we go to the
community to play. We have a choral, which makes presentation in several
places, here, in the city, and also out of it… we have …tickets, leisure
excursions with them, and journeys to the beach. We go to "Rei Clube" to
play snooker, ping-pong, among other things… (A9).

The using of collective spaces in "normal" times is a current practice
in the service. Sports here are also an aggregated factor, which provides
entertainment and leisure. The fact of arrogating legitimately social spaces,
is not a concession or a favor, it is a conquest that was reached over
the years. Not always the establish relations with the community were like
these. If by one side there were requests for a kind of assistance which
would bring resolution and put an end to revolving door, initially the
fear, the preconception and the stigma raised barriers, walls, which were
thrown down along of the time.

Morgado & Lima (1994) comment upon the models of de-institutionalization,
having this process in countries like the United States, Italy, Canada
and England as the basis for its analysis. Regarding the United States,
they refer to the process of de-hospitalization. This understanding, however,
cannot be conceived as de-institutionalization, since in this country this
practice was reduced to de-hospitalization. The authors point out five
serious consequences of de-hospitalization, such as: abandonment of critical
patients, high rotation of patients – characterized as revolving door,
non-monetary cost by mental disease, problems with justice/police and policies
of de-institutionalization movement.

Although not agreeing with the analysis of Morgado and Lima (1994) regarding
de-institutionalization (de-hospitalization), we agree with the authors
in relation to the characteristics of a good mental health model. Two pre-requirements
are considered essential for the implementation of the program, which are:
acceptance of the program by the community and the preparation of human
resources. Regarding the acceptance of the program by the community, two
aspects were characterized, such as the assurance of the participants’
objective conditions for the effective engagement in the activities, and
subjective dimension of living in community with mental ill patients. In
relation to the latter, the authors point out that this dimension is clear
by its opposite, that is, the tendency to internment. Well-prepared human
resources include the secure handling of basic pharmacology, focal psychotherapy
and family therapy, communitarian psychiatric nursing and social service.

We understand that in the service under study these requirements were
totally reached and even overcame in several aspects. In structuring the
service, the community was always actively involved. This involvement was
formal, when the presentation of the program to the alderman chamber and
informal through the establish interactions with the community, such as,
talking about mental health in several collective spaces (churches, associations,
schools, means of communication), in promotions, in the invitations to
the community in anniversaries of the institution, in the trade of vegetables
from the kitchen-garden produced by the users to the community, in festivals,
as well as the visits of the community to the house, firstly impelled by
curiosity then by solidarity. This involvement happened through several
ways, such as, through visitation of school children, aiming to know the
service, and also by the work of professionals in schools to talk about
mental health and insanity. These actions produced a favorable impact in
the demystification of insanity. In the community, it was possible to observe
clearly the dialectic jumping: from initial rejection – a house for crazy
people located in a noble area of the beach – to projects developed with
businesspeople in town.

In the analysis of the communitarian infrastructure formulated by Morgado
& Lima (1994), it is evident that the community interactive context
is central for the establishment of a good attendance system in mental
health. The authors visualize the revolving door as the best indicative
of communitarian assistance and the direct indicative of hospital assistance.

We agree with the authors and we consider the community engagement crucial
for the formulation of any proposal of de-institutionalization. However,
we considered a tendentious perception of the authors that, through the
example of revolving door, want to make people believe that there are not
available means to keep patients inside the communitarian structure. We
understand that transformations occur, more concrete, in the micro spaces,
through the deconstruction of a maniacal model strongly deep rooted in
the professionals and the common sense. This means to take responsibility
with the process of renovation, while the attribute to other organisms,
results in non-responsabilization.

Another thing is, for example, a patient who is willing
to … I’m going to buy a piece of cloth. We go out with these people and
go through the city, to the shops and we choose clothes for them, they
will look … this fits on me, this one doesn’t… we help him/her to buy,
with his/her money. Another thing we do, in the example of everyday life
… we have a choral … it is a choral here in the house, but it is open for
the community (A2).
Small everyday acts are shared with therapeutic fellows, such as go shopping.
These acts end in a routine practice which does not cause amazement to
sellers and store owners. Very soon patients are recognized and identified
by being from "Nossa Casa". This recognition is not just because of the
"faces" of mentally ill patients, but because it is a small city where
people know each other, and mentally ill patients lived and established
relations with the population. These factors corroborated for the city
to show itself as the best setting for the development of real changes,
where through real situations, with their variables, the difficulties of
the users can be worked out. This "real laboratory", in real life, is revealed
to be the best school of psychosocial rehabilitation for the users and
a learning for the team.
I think like that, I think it is not only they do
something in the workshops, you know, to sew, to embroider, etc. I think
like that, … it changes the hygiene, that … think like take care of the
house, we talk a lot about that with them (A3).

Another rehabilitated mechanism … is the self care…
we try somehow to make the patient like any other human being that walks
in our city … Anyway the hygiene, that is practiced by nursing, it is …
it is one of the factors not only in relation to people’s health to keep
clear, but also a rehabilitated thing, in the sense he/she doesn’t feel
ashamed. Many times, when the crisis is over se feels the same way of any
other person that is within the team that is going to the house (A8).

The care with him/herself, through healthy and suitable hygiene habits,
the management of the house and the several aspects involved here are discussed
with the users. The making in the workshops appears as a non-priority factor
for re-habilitation, firstly the capacity of performing everyday tasks
appears, inserted in a specific context, because the latter two are seen
as activities that change important aspects in the users’ life.

We rescue the differential between the entertainment and rehabilitation
approached by Saraceno (1999). To do something is seen as a synonymous
of entertainment, fulfilling the time, even if many times it is automatic,
useless, repetitive and non provided of finality. In this context, the
entertainment reduces the human being to a mechanic, stereotyped repetition
of some activities, in order to fulfill the time, since inactivity is not
tolerated.

We share Saraceno’s (1999) opinion regarding the search of disruption
of entertainment in the services of mental health. This disruption must
be approached in two fronts: the disruption of entertainment of the team
which gives assistance and the disruption of users’ entertainment – who
are the receivers of entertainment formulated by the teams.

And I think like that, that he/she in the workshop,
he/she learns something. Because we have carpentry, we have upholstery,
there are the packs, there are several workshops. And I think that he/she
learns something, and I think this brings benefits for him/her … after
he/she leaves here, even at home, if he/she wants to do something to sell
or … I think this will benefit, the workshop itself (A4).
The learning, in this context, starts being noticed in a different way
from to do, of the entertainment. There is the being here and afterwards,
to do something to keep him/herself. Thus, there is the idea of transitivity,
the passage through the institution and the return to life he/she had before
getting sick. Nossa Casa, after the users’ discharge, becomes a reference
point in which they run to help when they need.
Well, knowing the users, knowing their history, we
start working on things they have missed because of their disease, for
example: if he/she was a rural worker, we try toengage
him/her in an activity in this sense … (silence). Always putting him/her
inside its reality … helping, supplying, many times facilitating, the best
way (A10).
The centralization of therapeutic work having as its base the story of
life and not the deficits, in the diagnosis, in summary, the disease is
taken as a rehabilitated factor for the users. The respect to habits and
these users’ culture and the reinsertion in their origin activity is evident.
The respect to culture can be expressed, also, through simple everyday
activities, such as, a home visit to a patient that only speaks German
and/or ‘pomeran’ dialect by a worker who understands and speaks the same
language, is a routine practice.

An activity that workers understand and express themselves in ‘pomeran’
is the therapeutic group in the rural zone. During many years one of the
authors (A. D.) took part in this group. Because of the same language and
culture, the users express themselves easily, naturally. To facilitate
the best way does not mean to choose by the people. It means to help, to
be present, in the choice of several possible ways and to provide support
during the process.

Analyzing the data obtained, we learn that everyday life practices constitute
themselves a priori in the service. The focus is directed for a responsible
care, based on real appropriation of collective spaces. The rehabilitative
process is centered in the individuals’ necessities and possibilities,
in their life stories where previous abilities are considered and reinforced
and the cultural context in which the person is inserted.